jcoloproctol(rioj).2016;36(4):248–250
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Case
Report
Abdominal
wall
recurrence
following
laparoscopic
surgical
treatment
of
colorectal
cancer
–
case
report
夽
Kaiser
de
Souza
Kock
a,b,
Matheus
da
Silva
Pacheco
dos
Reis
a,
Estevão
José
Muller
Uliano
a,
Fernanda
Maraschin
Rech
b,∗aHospitalNossaSenhoradaConceic¸ão,Tubarão,SC,Brazil
bUniversidadedoSuldeSantaCatarina(UNISUL),Tubarão,SC,Brazil
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o
Articlehistory:
Received1February2016 Accepted22May2016 Availableonline6July2016
Keywords:
Videolaparoscopy Colorectalcancer Recurrence Metastasis
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Thetreatmentofcolorectaldiseasesbyvideolaparoscopy(VL)beganinthe1990s,bringing multipleadvantagesinthetreatmentofcancersingeneral,especiallybenigntumors. Specif-ically,incaseofcolorectalcancer(CRC),thelaparoscopicapproachoffersveryattractive prospects,suchasthestagingofadvancedlesionsandpalliativemanagementofpatients withincurableCCR.ThemostcontroversialaspectofthistechniqueistheuseofVLin curativeresections.Onequestionsthepossibilityofmetastasisinportalsrelatedtotumor recurrence,aswellastheviolationofoncologicalprinciples.Themechanisms responsi-bleforthisphenomenonmayberelatedtopneumoperitoneum,tissuemanipulation,and biologicalfactors.
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Recidiva
parietal
em
câncer
colorretal
operado
por
vídeo-laparoscopia
-relato
de
caso
Palavraschave:
Vídeo-Laparoscopia CâncerColorretal Recidiva Metástase
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e
s
u
m
o
Otratamentodasdoenc¸ascolorretaisporvídeo-laparoscopia(VL)seiniciounadécadade90, trazendoinúmerasvantagensnotratamentodoscânceresemgeral,sobretudonoscânceres benignos.Especificamentenocasodocâncercolorretal(CCR)oacessolaparoscópicooferece perspectivasbastanteatraentes,comooestadiamentodelesõesavanc¸adaseomanuseio paliativodepacientescomCCRincurável.Oaspectomaiscontroversodessatécnicareside nautilizac¸ãodaVLemressecc¸õescurativas.Questiona-seapossibilidadedemetástaseem
夽
StudylinkedtotheHospitalNossaSenhoradaConceic¸ão,Tubarão,SC,Brazil.
∗ Correspondingauthor.
E-mail:fermrech@hotmail.com(F.M.Rech).
http://dx.doi.org/10.1016/j.jcol.2016.05.004
jcoloproctol(rioj).2016;36(4):248–250
249
portaisrelacionadascomarecidivatumoral,alémdaviolac¸ãodeprincípiosoncológicos. Osmecanismosresponsáveisporessefenômenopodemestarrelacionadosao pneumoper-itônio,manipulac¸ãotecidualefatoresbiológicos.
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Thetreatmentofcolorectaldiseasesbyvideolaparoscopy(VL) beganinthe1990sandseveraladvantageshavebeen gradu-allydemonstrated,especiallywithregardtobenigndiseases. Laparoscopicsurgeryofthegastrointestinaltract(GIT)results in less postoperative pain, less prolonged paralytic ileus, shorterhospital stays, and better cosmetic results.1 These
advantagesenshrinethisapproachtothesurgicaltreatment ofgallbladder andgastroesophagealtransition,makingthis anextremelysafeandeffectiveoptionforthemanagementof inguinal-femoralherniasandcolorectaldiseases.2
Incolorectalcancer(CRC),thelaparoscopicapproachoffers very attractive prospects,such as the staging ofadvanced lesionsandthepalliativemanagementofpatientswith incur-ableCRC.3However,herethemostcontroversialaspectisthe
useofVLincurativeresections,withthequestioningofthe possibilityofviolationofoncologicalprinciplesandofanearly recurrence(especiallytheportalmetastasisphenomenon).It ispostulated thatthe mechanisms responsibleforits gen-esisrelatetopneumoperitoneum,tissuemanipulation,and biologicalfactors.4
Clinical
case
Afemalepatient,aged91,aretiredfarmer,borninTrezede Maio/SC,withastheniaandsignificantweightlossassociated withapictureofnormocytic/normochromicanemiawaiting for clarification. This patient had a history of Alzheimer’s dementia,systemichypertension,dyslipidemiaanddiabetes mellitusundergoingtreatment.Onphysicalexamination,the patientpresentedweightlossandpalemucousmembranes, andaslightlypainful,palpableabdominalmassintheright flank,withnootherchanges.
Upperendoscopyandcolonoscopystudieswererequested, andthis last procedurerevealed anulceratedlesion inthe hepatic angle; then, biopsies were performed, which con-firmedthediagnosisofcolorectaladenocarcinoma.Imaging studiesforstagingwererequested,andacomputed tomogra-phyoftheabdomenshowedaliveranglelesion withlocal peritonealinfiltrationandlymphnodeenlargementintheroot ofthemiddlecolicartery(Fig.1).Therefore,thepatient under-went a videolaparoscopicright colectomy dueto the right colonadenocarcinomainstageIII,accordingtothe classifi-cationofDukes,withgoodpostoperativeevolution.
Fourteenmonthspost-surgerythepatientpresenteda veg-etating lesion inthe portal incision on the left iliac fossa, associated with local pain of mild intensity. It was sug-gestedthe hypothesis parietalrecurrence duetothe colon
Fig.1–Computedtomographyoftheabdomenshoweda liveranglelesionwithlocalperitonealinfiltrationand lymphnodeenlargementintherootofthemiddlecolic artery.
adenocarcinoma,andaresectionofthelesionwasperformed, withsubsequentconfirmationofrelapseby anatomopatho-logicalexamination.
Discussion
AccordingtoINCA(InstitutoNacionaldeCâncer)data, colorec-talcanceristhethirdmostfrequentneoplasminmen,soon afterprostateandlungcancer,andthesecond-mostfrequent inwomen,secondonlytobreastcancer.Itisestimatedthatin 2014therewere30,660newcasesofcolonandrectalcancer.5
By being aminimally invasiveprocedure, the treatment ofGITcancerbyvideolaparoscopyhasbecomethepreferred accessrouteinthe palliativehandlingofadvancedtumors, enabling the complementation ofpreoperativestaging and allowingthe makingofintestinaldiversions andresections withlessriskandbetterpostoperativeoutcomes.1
250
jcoloproctol(rioj).2016;36(4):248–250portalsused,arealsonotdifferent.Thisriskisconsideredas notexclusiveforlaparoscopicresections,butanunfortunate consequenceofthelearningcurveand/orofanadvanced dis-ease,takingasmallerproportioninascenarioofanadequate trainingandtechnicalskill.
Nowadays,itisacknowledgedthatparietaldissemination inlaparoscopicsurgeryisacomplexandmultifactorial prob-lemthatalsooccursingynecologicproceduresandingeneral andthoracicsurgery.Itisimportanttonotethatnotalltumor recurrencesoccurattheincisionproducedinordertoextract thepiece.Relapsesoccurevenincasesinwhichthepiecewas removedwrappedindevicesdesignedtopreventdirect con-tactwiththeabdominalwall.Tumorrecurrencesoccureven incaseswhosetumorlocationwasrestrictedtothecolonwall (DukesA).
Otherpreventivemeasurestoavoidthiscomplicationare thefixationoftrocarsintheabdominalwall,avoidanceofan excessivemanipulationofthetumor,slowemptyingofthe pneumoperitoneumandreplacementofCO2initsproduction,
andwashingthetrocarsandincisionswithaniodine-based solutionpriortotheirremoval.6
Nonetheless, giventhe evidence presented, the authors concludethatprospectiverandomizedstudiesareneededto comparevideolaparoscopicversusconventionalaccessinthe radicaltreatmentofcolorectalcancer,despiteitsadvantages, whichstilloutweightheircomplications.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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LaparoscópicaColorretal.ResultadosdoInquéritoNacional Brasileiro–2001.RevBrasColoproct.2001;21:135–43.
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